Though ejaculation often occurs normally and is an intensely pleasurable sensation for most men, it is an extremely complex phenomenon that is regulated by many different systems. Hence, things often can, and do go wrong.

an has forever been obsessed with semen and everything associated with it (seminal matters ?!). This includes, among others, its color, consistency, odor, quantity, loss and force of ejaculation.

For some strange reason, miraculous properties have been ascribed to this rather ordinary body fluid by nearly every culture in human history. The total quantity of a man's semen was assumed to be a valuable lifetime constant from which all release had to be very frugally rationed. Though this hypothetical quantity was never determined and the quotas for rationed release never specified, loss of semen was nonetheless associated with `weakness'. Even now, it is quite common to see educated, well-placed men complaining of `weakness' from head to toe, ostensibly because of their belief that they have lost more semen than was good for them.

It is interesting to note that human spermatozoa were first seen under the microscope by Leeuwenhoek only in 1674 and that scientific proof that the sperm fertilizes the ovum to produce pregnancy was first available only in 1779 (Spallanzani). Yet, theories about the `vital fluid' abounded centuries ago, especially the one equating one drop of semen to forty drops of blood !! Quacks and `sexologists' help considerably in perpetrating these beliefs across all strata of society even today.

The act of seminal ejaculation, likewise, is poorly understood by most. Erotic films and literature depicting `bucketfuls of cum squirted several feet' don't help matters and tend to confuse even the well - informed. Though ejaculation often occurs normally and is an intensely pleasurable sensation for most men, it is an extremely complex phenomenon that is regulated by many different systems. Hence, things often can, and do go wrong.

Let's take a look at some of the common ejaculatory disturbances. (It must be emphasized that a detailed classification and discussion of these is outside the scope of this article.)

Premature ejaculation

Delayed (Retarded) ejaculation

Retrograde ejaculation

Anejaculation

PREMATURE EJACULATION

Premature ejaculation is an extremely common condition. Kinsey, in his landmark report, had stated that it affects as many as 75% of all men. In today's context, premature ejaculation (PE) becomes especially relevant because of the increasing emphasis on female sexual gratification. Today's woman will not take anything lying down unless it is good enough (pun intended, of course). However, premature ejaculation seems to be nature's original design. The Kama Sutra has classified PE as one among many normal ejaculatory patterns.

From the standpoint of procreation of the species, prematurity of ejaculation seems to confer an evolutionary advantage. Early man lived in dangerous environs and had to finish mating in a hurry. He therefore had very little time in which to deposit his semen in the female's vagina and ensure propagation of the species. The continuation of this primitive PE streak in humans perhaps explains the preponderance of the condition in modern man.

PE is hard to define because its spectrum is so vast. Some men ejaculate at the mere thought of coitus. Others seem to be able to last long enough by average standards but are yet unable to gratify their partners. Hence, attempts have been made to quantify PE objectively on the basis of timing of intercourse up to the point of ejaculation, the number of pelvic thrusts until ejaculation, partner satisfaction, etc.. Researchers have actually placed stop-watches and thrustometers in patients' bedrooms.

None of these methods, however, is ideal. The current working definition of PE is the one published in the fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders - the DSM-IV. Briefly, the DSM-IV defines PE as "persistent or recurrent ejaculation with minimal stimulation before, during or shortly after penetration and before the person wishes it". Even this hasn't been standardized. Many additional parameters need to be looked at, and the importance of physical factors (increasingly incriminated in PE) needs to be incorporated (see Table below).

PHYSICAL (NON-PSYCHOLOGICAL) CAUSES

Injury to sympathetic nervous system (e.g. following surgery for abdominal aortic aneurysm)

Definitions notwithstanding, PE, despite many claims to the contrary, is a difficult condition to treat. Since PE has been a human concern for centuries, every system of medicine and every culture boasts its own unique `cures' for the condition. Many of these have acquired a reputation for efficaciousness because of their strong placebo effect. Since PE is often a psychological disorder, even substances without any real pharmacological effect on the ejaculatory apparatus can work by the power of suggestion (placebo).

Some decades ago, psychosexual methods of treatment gained tremendously in popularity. One such was the `start-stop' method, which was propounded by Semans and then popularized by Helen Singer Kaplan. The other was the `squeeze' technique described by Masters and Johnson. These techniques held sway for many decades, largely because of the unavailability of other treatment methods. However, it soon became clear that the initial success rates claimed with these were not sustainable and that, over time the success rates had dwindled to 25%. Besides, these techniques are very tedious to employ and unsuitable for today's space age. Today, research is centered on understanding the central and peripheral neurological control of the ejaculatory process and regulating it with drugs.

The various treatment options for PE are summarised in the Table below. The current treatment of choice seems to be medication with the SSRI (Selective Serotonin Reuptake Inhibitors) and allied groups of drugs.

TREATMENT OF PREMATURE EJACULATION

Pharmacological therapy

dopamine antagonists

antidepressants

anxiolytics

others

Topical anesthetics

Microsurgery

Psychological treatment

Miscellaneous agents

DELAYED (RETARDED) EJACULATION

Delayed or retarded ejaculation is a condition which is, in many ways the exact opposite of premature ejaculation. It is defined as a persistent difficulty in achieving ejaculation despite the presence of adequate sexual desire, erection and stimulation. On the face of it, this might seem to be a good condition to suffer from because it carries connotations of great staying power. This may be true sometimes, especially if the female partner also requires a long time to reach orgasm. Often, however, it is more a cause for worry than for rejoicing. The male often goes on for a half hour or more with little sexual pleasure, and constantly worries about when he is going to finish. The female partner usually has already attained orgasm and waits eagerly for the man to finish. She stops lubricating shortly after she has attained orgasm and the remainder of the sex act is a painful formality. Situations such as these can lead to a lot of relationship problems between the partners.

In its most severe manifestation, delayed ejaculation takes the form of ejaculatory incompetence, a condition where the man can never ejaculate inside the vagina. This poses additional problems when the couple wants to have a baby (see under Anejaculation - vide infra).

Positive reinforcement of operative conditioning associated with masturbation might play a central role in the development of delayed ejaculation.

A very common reason for delayed ejaculation is this: most men have their first orgasm through masturbation. Many men go on to have quite a few more orgasms by continuing to `take matters into their own hands'. And, many men exert much more pressure with their hands than they are likely to experience during intercourse. In doing so, they essentially train themselves to sexually respond to lots of pressure. One reason young males use strong pressure during masturbation is they're often rushing to finish so they don't get caught. Then, as adults, they mistakenly think they need that same pressure to reach orgasm. Many men can learn to reach orgasm with a partner if they practice self-stimulation slowly and with much less pressure than usual. This can be done at any time, whether with a partner or not. Of course, self-stimulation just before one is likely to be sexual with another person must be avoided.

`Working' at sex seldom works well - whether one is doing the working or being worked on. At the root of this approach to sex is the belief that there is a formula for how sex is supposed to go. This belief is one of the main reasons why people get into sexual difficulties. Formulae are necessary for creating chemical reactions, but they nearly always stymie sexual reactions. Working to follow a formula requires people to ignore both their own physical sensations as well as the signs of their partner's pleasure. It obstructs spontaneity and dictates a script that makes partners deny one another's uniqueness. Some men get into the habit of thinking about how difficult it's been in the past to reach orgasm when they're having sex with a partner. This slows down arousal and makes orgasm that much more elusive.

So what do you do if you suffer from delayed ejaculation ?

Focus on things that are sexy to you. It can be some aspect of your partner's personality or body, a hoped-for experience or an embellishment of the situation you're currently in. The brain has an amazing way of propelling sexual arousal forward even when the physical stimulation is different or less intense than usual. Teach your partner how to stimulate you by hand or orally in the way you like best. Many women think that all men like more or less the same things. While there tend to be some common characteristics, good sex can become great sex if subtle nuances and personal preferences and kinks are part of it. This means that you'll want to be in a state of mind that welcomes the sexual sensations your partner is offering you. Set aside concerns about how you look as you become aroused. Luxuriate in the physical gifts you're getting moment by moment. Check whether you are focusing excessively on giving your partner pleasure. Sex with a partner is not about giving only; it is also as much about receiving. Decide to really be comfortable receiving pleasure. You'll feel better and so will your partner.

There's another common approach to sex that slows things down - often intercourse is begun too soon in the sexual encounter. Many men with delayed ejaculation have the idea that they'd better start working at it early on because they fear that their partner will tire out if the whole experience takes what the partner considers `too long'.

This leads to missing many an erotic experience that builds the arousal level - not to mention missing out on a lot of fun. Rushing to intercourse, in essence, short-circuits things. Many people feel that going straight to intense genital stimulation numbs what could have been intense pleasure if only one's partner had built it up in graded fashion.

Give up watching the clock with an arbitrary time limit in mind. Unless your partner has made specific complaints, let go of that pressure on yourself. Many people enjoy a man's taking his time while moving through his sexual responses. Keep in mind that you can `take matters into your own hands' while in bed with a partner. Many men and women bring themselves to orgasm while a partner adds extra caresses or kisses. You might be underestimating how arousing it could be to your partner to see you stimulate yourself.

Take a look at how you feel emotionally during sex. Are you angry? Anxious? Afraid? Depressed? These emotions activate the sympathetic nervous system, which in turn blocks the arousal needed to reach orgasm.

Other factors that can be contributory to delayed ejaculation include obsessive-compulsive disorders, marital conflict and chronic substance abuse (alcohol and drugs). Delayed ejaculation is often related to anger or resentment towards women and an oppressive upbringing. It could also result from lack of emotional involvement with the partner and fear of commitment.

Many organic (physical) causes too can contribute to delayed ejaculation. These include many neurological and endocrine illnesses, diabetes, cancer, prostate problems, drugs such as those employed for the treatment of psychiatric illnesses and high blood pressure, and surgical intervention that can affect the ejaculatory apparatus. Physical and psychological factors often co-exist. All these conditions will require specialist intervention.

RETROGRADE EJACULATION

Retrograde ejaculation (which can also present as Anejaculation - vide infra), as its name implies, is a condition where the seminal fluid is ejaculated backward (retrograde) into the urinary bladder instead of forward (antegrade), as is the norm. (I once had a patient in my consulting chamber who asked me, "Dr. Krishnamurti, are you trying to tell me that instead of coming, I go ?". ) This usually occurs because the neck of the urinary bladder, which normally closes to block such retrograde flow, is unable to do so. Such inability usually results from neurological or physical damage to the bladder neck, which in turn can result from a variety of clinical conditions.

There was this man from Kent
Who, to a football match went
He stood at the goal
And activated his pole
But instead of coming, he went !

Patients with retrograde ejaculation usually achieve orgasm normally and feel the sensation of having ejaculated. However, little or no seminal fluid emerges from the penis. Instead, the patient often notices that the post-ejaculatory urine, i.e. the urine passed after sexual intercourse, is cloudy with semen.

Diabetes is an extremely common cause of retrograde ejaculation (also a very common cause of impotence). This occurs because diabetic neuropathy impairs the sympathetic autonomic nerve supply to the bladder neck. Nearly 32% of diabetics will have some degree of retrograde ejaculation (50% will suffer impotence). Other causes of retrograde ejaculation are spinal cord lesions and injuries, operations on the spine, retroperitoneum or pelvic organs, surgery on the bladder neck and prostate and again, many, many drugs that affect the neurological control of the bladder neck.

Retrograde ejaculation is again a difficult condition to treat. Drugs that are normally used to treat this condition, such as imipramine, ephedrine and phenylpropanolamine are not always effective. Many patients reconcile themselves to the condition and learn to live with it. Many lead otherwise normal sex lives.

For men who want to father children, however, retrograde ejaculation becomes a serious matter since these men cannot deposit their semen inside the vagina. These men can be treated by retrieval of sperms from the urinary bladder followed by assisted reproduction - with good results.

ANEJACULATION

Anejaculation, as its name implies, is a condition characterized by the absence of ejaculation. The causes can be psychological and physical. Psychological anejaculation is usually anorgasmic i.e. unaccompanied by orgasm. This again, can be situational or total. Situational anejaculation means that a man can ejaculate in some situations but not in others. For instance, a man may be able to ejaculate and attain orgasm with one partner but not with another. This usually occurs when there is a psychological conflict or a relationship difficulty with one partner. Or he may be able to ejaculate quite normally during masturbation but not during intercourse. It can also occur in stressful situations, as when a man is asked to collect a sample of semen in the laboratory for infertility treatment. In total anejaculation, the man is never able to ejaculate when awake. Deep-rooted psychological conflicts are usually the cause. Such men, however, usually have normal nocturnal (night) sleep emissions.

Physical (organic) anejaculation, which includes retrograde ejaculation (vide supra), can occur due to neurogenic and obstructive causes. Many of the neurogenic causes are similar to those outlined earlier. It must be reiterated that diabetes is an important cause.

Treatment

Treatment depends on the cause and includes psychosexual counselling, drugs such as ephedrine and imipramine, vibrator therapy and electroejaculation. The last is a procedure in which an electrical current is applied to the ejaculatory organs to stimulate ejaculation. Success rates are nearly 100 %. Obstructions to the ejaculatory pathway will, of course, need surgery.

The Multicept Vibro-ejaculator & the Seager Electro-ejaculator

We have seen how even `normal' men are obsessed with seminal matters. It is easy to imagine, therefore, how crippling a real ejaculatory dysfunction can be. Yet, it is not uncommon in clinical practice for a physician to dismiss a patient's complaints as trivial and ask him not to make much ado of it. The complexity of ejaculatory disturbances necessitates treatment only by experts with a special interest and experience in treating these conditions. Despite this, some cases might be refractory to treatment.